Chasing the Rabbit: Official Blog by Author Steven Spear

Dear Friend and Colleagues,

Congress and the opinionators are plowing ahead on health care reform that is the wrong cure for the wrong problem.  Committed to competition among insurers (with a public option to add competition), they entirely miss the key point: Too many resources are wasted and too much pain is caused by the presence of inept organizations who provide crummy, expensive care because they aren’t filtered from the system.

Why aren’t they? When you decide where to get care, you lack information sufficient to pick the most effective and most efficient, so you trust your wealth and well being to a blind draw.  This drives business to those who don’t deserve it and away from those who do.

The solution? Transparency about provider performance to allow informed choice by payers and patients.

Below, I’ve attached a letter I sent to the NY Times expanding on these points.

When you’ve read it, please comment and let me know what you think.

Ideally, I would like to get sufficient feedback that we can send an op ed to major papers, letters to Congress, and the like saying what _we_ want in a reform package—we being real patients, real providers, those in the thick of trying to reform the delivery of health care at the bedside and in the exam room, not just the know nothing talking heads.

Here are some ideas. Let me  know what you think we should add, modify, or delete.

1. Visibility about information.  Without it, we’re picking providers by shooting in the dark.  Let providers compete for patients who are making informed choices.
2. Bona fide competition among insurers, so we get the best _portable_ plans at the best price.
3. A social safety net for the underprivileged who cannot provide for themselves.

I’m sorely convinced that if we don’t act, what comes out of Washington may actually be worse than what we have.  Certainly, it will be much worse than it can be or should be.

Steve

Dear Sir or Madam:

According to the NY Times opinion pages (”A Public Health Plan,” editorial NYTimes, June 20, 2009; “Health Care Showdown,” Paul Krugman, NYTimes, June 22, 2009), the primary problem with US health care is the lack of competition among insurers.  Certainly, local monopolists will inflate fees and deflate service, and one would expect that genuine competition among several providers is better than none.

However, even where there is competition among insurers, quality is poor and costs are high.  Why?  There is insufficient competition among providers, and this lack of competition matters a lot.

Currently, there are extraordinary differences in performance, with some providing great care–consistently good outcomes, few if any complications, minimal waits and available access, all at reasonable costs, while others provide terrible care–inconsistent outcomes, many complications, and high costs.

Given those painful discrepancies, patients and payers should swarm to the good and spurn the bad.  But they don’t.

Why?  Because we don’t have sufficient information to know better, and, without informed choice, far too much traffic goes to those who burn a lot of resources while providing too little, and too little traffic goes to those who are most effective and most efficient.  (Imagine such blindness going into a purchase by considering buying a car, and not knowing in advance whether you will get a Lexus or a Yugo for your hard earned money, or buying a plane ticket not knowing to which airport you will arrive.)

Because those who receive care and pay for care cannot determine well where to get care, the overall level of care is tragically lower than it need be and its costs are astronomically too high.

Here is a starting point to solving that problem.  There are certain events that just should never happen (just like the wheels of your car or the wings of your plane should never fall off).  Patients on ventilators shouldn’t get pneumonia, patients with catheters shouldn’t get urinary tract or blood stream infections, patients shouldn’t suffer surgical site infections, patients should not fall and injure themselves, and patients should never get the wrong medication, in the wrong dose.

When these things do happen, it is not because “health care is complicated” or because “every patient is different.”  It is because there was a breakdown in the delivery of care.  The management of care was broken.

Therefore, let us know how often it gets broken.  Require all organizations to post how well they are doing against a standard of ‘zero’ on these never events.  Next, build out other measures of efficacy and efficiency across the span from preventative and primary care to chronic, acute, intensive, and extended care.  Then, people can make informed choices as to whom to trust with their wealth and well being and whom to fear.

Without doubt, a caring society will ensure that the least fortunate receive health care just as we try now to make sure no one goes hungry or homeless. And yes, it is undoubtedly important that there be competition among insurance providers.  No one wants to get fleeced.

However, if we want bona fide reform that successfully increases quality and affordability (and hence access), we have to start rewarding great providers at the expense of the laggards so the money we put into the system gets well spent, not squandered.

Only then can we get health care for all in a way that isn’t bankrupting.

Yours,
Steve Spear

Senior Lecturer: MIT-Engineering Systems Division
Senior Fellow: Institute for Healthcare Improvement

Related posts:

1. Spear on Bloomberg: What’s health care reform missing? Quality!
2. Measuring Value-Added, not Compliance, Key to Health Care Reform
3. Outcomes Measurement: The Linchpin of Healthcare Reform
4. Theory and Evidence for Repairing Health Care Markets So Markets Can Repair Health Care Delivery…
5. Brooks Right, Krugman Wrong on Healthcare ‘Reform’ Legislation